International Journal of Science and Research (IJSR)

ISSN (Online): 2319-7064

Index Copernicus Value (2015): 78.96 | Impact Factor (2015): 6.391

Abnormal Umbilical Cord Coiling Index and Its

Relation to Adverse Perinatal Outcome
Dr. Richa Jha1, Dr. Renu Rohatgi2
1
Senior Resident, Department of Obstetrics and Gynaecology, Nalanda Medical College and Hospital, Patna
2
Professor and Head, Department of Obstetrics and Gynaecology, Nalanda Medical College and Hospital, Patna

Abstract: Background: The umbilical cord is vital to the development, well being and survival of the fetus. A coil of the cord is defined
as a complete 360 degree spiral course of umbilical vessels around Whartons jelly. Sonographically, the Umbilical Coiling Index (UCI)
is defined as the reciprocal of the average distance between a pair of coils. Hypocoiled cords are those with UCI < 10th centile while
hypercoiled cords are those with UCI >90th centile. Methods: The study was conducted in the Department of Obstetrics and
Gynaecology, Nalanda Medical College , Patna, Bihar. Hundred patients attending GOPD were selected for the study over a period of
one year( October 2015 October 2016). The effect of Umbilical cord coiling index on the antenatal outcome . (Presence of gestational
hypertension& IUGR) and fetal outcome ( Presence of meconium stained liquor, APGAR Score at birth and requirement of NICU
admission) was studied. Results: Hypocoiled cords (UCI < 10th centile) were found to be associated with adverse fetal outcomes like
presence of MSL and low APGAR score at 1 & 5 min. Hypercoiled cords ( UCI > 90 th centile) were found to be associated with a higher
incidence of gestational hypertension in mother and IUGR in fetus.

Keywords: Umbilical artery Coiling Index, Gestational Hypertension, Meconium Stained Liquor, IUGR, APGAR Score

1. Introduction 3. Methods and Materials

The umbilical cord is the lifeline of the fetus as it supplies
water, nutrients and oxygen to the growing fetus. The
average length of the cord is 55 cm wit the usual range of 30
100 cm. Its diameter varies from 0.8 2 cm. Its thickness
is not uniform but foldings and tortuosity of the vessels
create modulations on the surface of the cord. In no other
part of fetoplacental unit, the vital blood vessels are so
vulnerable to kinking, compression, traction and torsion. A
coil is defined as a complete 360 degree spiral course of
umbilical vessels around the whartons jelly. The origin of
coiling of umbilical cord vessels is not known but
hypothesis include fetal movements, active or passive
torsion of the embryo, different umbilical vascular growth
rates, fetal hemodynamic forces and arrangement of
muscular fibres in the umbilical arterial vessels.
Sonographically, the umbilical coiling index is calculated by
measuring the distance between two adjacent coils from the
right outer surface of the vascular wall to its next twist. The
Umbilical Cord Coiling Index is defined as the reciprocal
of the average distance between a pair of coils. Abnormal
UCI includes both Hypocoiled cords (UCI < 10 th centile)
and Hypercoiled cords (UCI > 90th centile).
2. Aims and Objectives
To find out whether abnormal UCI is related to adverse
fetal outcome (IUGR, Meconium Stained Liquor, Low
APGAR Score)
To find out whether abnormal UCI has any adverse effect
on mother (Increased incidence of gestational
hypertension)
To identify the fetuses at risk and their timely
management so as to reduce perinatal morbidity and
mortality
The work was carried out on 100 patients attending GOPD
of Nalanda Medical College and Hospital, Patna over a
period of one year, October 2015 to October 2016 with the
following inclusion crieteria:
Patients with singleton live pregnancy without any
congenital abnormality
Patients with history of gestational hypertension in
present or previous pregnancies
Patients with history of delivery of previous SGA/ IUGR
babies
The following patients were excluded from the study :
Multifetal gestation
Known congenital anomalies in the fetus suffering from
any medical / surgical illness which would have an
untoward effect on the growth of the fetus
Inadequate or an inappropriate longitudinal images of
umbilical cord to allow an accurate antenatal umbilical
coiling index mesurement
Detailed history taking and general as well as routine
obstetrical examination was done. All routine antenatal
investigations were done. Ultrasonography along with
colour Doppler studies to note the umbilical cord coiling
pattern and to find the UCI was done from 24 wks gestation
onwards according to reliable LMP and sonologic
confirmation of first trimester.
The pitch of one complete vascular coil was measured by
ultrasonography in a midsection of umbilical cord. The
mean of upto 3 coils from different segments of the
umbilical cord was used for analysis. Measurement of this
pitch, defined as distance in cm from the inner edge of the
arterial wall to the outer edge of the same arterial wall of the
next coil ipsilaterally was taken. If UCI was too low to

Volume 6 Issue 5, May 2017

www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
Paper ID: ART20173609 1581
 International Journal of Science and Research (IJSR)
ISSN (Online): 2319-7064
Index Copernicus Value (2015): 78.96 | Impact Factor (2015): 6.391
measure one complete coil in view, we measure the largest statistically significant. SPSS was used for statistical
segment of cord without a complete coil. analysis.

The antenatal UCI (aUCI) was calculated as the reciprocal 4. Observation

value of the mean of the three measurements of the pitch of
one complete coil, or as the reciprocal value of the largest Demographic Factors
length of umbilical cord without one complete coil.
1) Age Wise Distribution of Patients
The distance between two pairs of coils in a normocoiled
cord is 2.61 cms.

Then aUCI was calculated as

aUCI= 1/distance in cms= 1 / 2.6 = 0.38
Normocoiled cord: 0.38+0.11 coils/ cm
Hypocoiled cord :<0.27 coils/cm
Hypercoiled cord :>0.49 coils/cm

Patients were followed till delivery. Umbilical cord was

examined post delivery and was correlated to UCI calculated
antenatally. Baby was examined, APGAR at 1 and 5 min
were taken. Birth weight of the baby and requirement for
NICU admission was noted. All babies were followed until
they were either discharged from the hospital or they
succumbed. Results were presented as numbers and 2) Umbilical Coil Coiling Index
percentages. Chi square was used to analyze categorical
data. A p value of 0.05 or less was considered to be

3) Gestational Age at Delivery

Volume 6 Issue 5, May 2017

www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
Paper ID: ART20173609 1582
 International Journal of Science and Research (IJSR)
ISSN (Online): 2319-7064
Index Copernicus Value (2015): 78.96 | Impact Factor (2015): 6.391
4) Correlation of Gestational Hypertension with UCI 12 patients with hypercoiled cords. The correlation of low
Gestational Hypocoiled Normocoiled Hypercoiled APGAR Score at 5 min with hypocoiled cords showed p
Hypertension value of 0.003 which was significant.
Present 05 09 07
Absent 12 62 05 Hence both hypocoiled and hypercoiled cords were found to
P Value 0.5 0.002 be associated with adverse maternal and fetal outcomes.

5) Correlation of Fetal Risk Factors with UCI

6. Discussion
Risk Factors Hypocoiled Normocoiled Hypercoiled
The umbilical coiling index has been found to be an
IUGR Present 04 13 07
effective indicator of perinataloutcome. The aim of this
Absent 13 58 05
P Value 0.793 0.009
study was to find the relationship between UCI and various
MSL Present 06 05 01 maternal and perinatal factors. The mean UCI in our study
Absent 11 66 11 was 0.24+0.09 which was similar to the study done by
P Value 0.004 0.956 Ezimokhai et al.(2001)
APGAR AT 1 < 4 12 19 04
MIN Among previous studies, Ezimokhai et al. [9] found
>4 05 52 08 hypercoiled to be associated with extremes of maternal age
P Value 0.001 0.84 (<20 and >35 years). None of the other studies found age to
APGAR AT 5 < 7 10 15 02 be a significant factor. Our study did not find any significant
MIN association with parity, anemia, Rh negative pregnancy,
>7 07 56 10 presence of heart disease, or infertility. No significant
P Value 0.003 0.60 association was found between UCI and any of these factors
in previous studies also.
5. Results
Preeclampsia was found to have a significant association
Out of the total 100 patients studied, 16 patients were in the with hypercoiled (=0.002). Ezimokhai et al. also
age group < 20 yrs, 64 were between 21 30 years and 20 demonstrated a significant association between hypercoiled
patients were more than 30 years of age. Majority of the cords and preeclampsia. Similar findings were found in
patients had normocoiled cords (71/100). Hypocoiled cords studies done by Gupta et al. [10]. The coiled umbilical cord,
were seen in 17/100 patients and hypercoiled cords were because of its elastic properties, is able to resist external
seen in 12/100 patients. Out of the 100 patients studied, forces that might compromise the umbilical vascular flow.
preterm delivery ( gestational age < 37 wks) occurred in 24 This might explain the association of hypercoiling with
patients while the remaining 76 patients delivered at term. preeclampsia.

In our study, gestational hypertension was seen to be present
in 21/ 100 patients. The correlation of gestational
hypertension with abnormal UCI has been shown in Table 1.
Hypercoiled cords have been associated with the presence of
Gestational Hypertension with p value of 0.002 which was
significant.
Among the fetal risk factors, IUGR was seen to be present in
24/100 patients. IUGR was seen to be present in 7 out of 12
patients with hypercoiled cords. The correlation showed a p
value of 0.009 which was significant.
Meconium staining of liquor was present in 6 out of 17
patients with hypocoiled cords, 5 out of 71 patients with
normocoiled cords and 1/12 patient with hypercoiled cord.
Correlation of meconium stained liquor with hypocoiled
cords showed a p value of 0.004 which was highly
significant.
APGAR Score at 1 min <4 was present in 12 out of 17
patients with hypocoiled cords, 19 out of 71 patients with
normocoiled cords and 4 out of 12 patients with hypercoiled
cords. Correlation of low APGAR score at 1 min with
hypocoiled cords showed p value of 0.001 which was
significant.
APGAR score at 5 min <7 was seen in 10/17 patients with
hypocoiled cords, 15/ 71 patients with normocoiled and 2 /
Volume 6 Issue 5, May 2017
www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
Paper ID: ART20173609
FHR variations were found to have a highly significant
association with hypocoiled cords. Literature has found a
consistent association between intrapartum FHR
decelerations and abnormal UCI. Strong et al and de Laat el
al found FHR decelerations to be associated withhypocoiled
cords. According to them, hypocoiledcords are less flexible
or more prone to kinking and torsion which makes them less
tolerant to withstand the stress of labour. Rana et al and
Ercal et al found FHR decelerations to be significantly
associated with hypocoiled cords. Rana et al felt that coiling
provides turgor and compression resistant properties to the
cord which become compromised as the cord becomes
hypocoiled.
An initial low APGAR (<4 at 1 minute) and (<7 at 5
minutes) was found to have a significant relationship with
both hypocoiled cords in our study. The values were
0.001and 0.003, respectively. A similar result was obtained
by Gupta et al. [10] and Kashanian et al.
Intrauterine growth retardation was shown to be
significantly associated with hypercoiled cords, p value of
0.009. Literature has found a consistent association between
hypercoiled and IUGRbabies, as shown by Rana et al, Raio
et al. and de Laat et al. However, the authors were unable to
give a satisfactory explanation for this casual association.
1583
 International Journal of Science and Research (IJSR)
ISSN (Online): 2319-7064
Index Copernicus Value (2015): 78.96 | Impact Factor (2015): 6.391
Meconium staining of the amniotic fluid was found to have a outcome. International Journal of Gynecology&
significant association with both hypocoiled (=0.004). Obstetrics. 2006;95:813. [PubMed]
Although similar findings were noted in studies done by [14] De Laat MWM, Franx A, Van Alderen ED, Nikkels
Strong et al. and Ezimokhai et al, they did not offer a PGJ, Visser GHA. The umbilical coiling index, a review
specific explanation for the observation. of the literature. Journal of Maternal-Fetal and
Neonatal Medicine. 2005;17(2):93100. [PubMed]
7. Conflict of Interests [15] Strong TH, Jarles DL, Vega JS, Feldman DB. The
umbilical coiling index. American Journal of Obstetrics
There was no conflict of interests among the authors of the and Gynecology. 1994;170(1, part 1):2932. [PubMed]
study [16] Raio L, Ghezzi F, Di Naro E, et al. Prenatal diagnosis of
a lean umbilical cord: a simple marker of the fetuses at
References risk. Ultrasound in Obstetrics
&Gynecology. 1999;13(3):157160. [PubMed]
[1] Chaurasia BD, Agarwal BM. Helical structure of the
human umbilical
cord. ActaAnatomica. 1979;103(2):226230. [PubMed]
[2] Lacro RV, Jones KL, Benirschke K. The umbilical cord
twist: origin, direction, and relevance. American
Journal of Obstetrics and
Gynecology. 1987;157(4):833838. [PubMed]
[3] Edmonds HW. The spiral twist of the normal umbilical
cord in twins and in singletons. American Journal of
Obstetrics and Gynecology. 1954;67(1):102
120. [PubMed]
[4] Strong Jr. TH, Elliott JP, Radin TG. Non-coiled
umbilical blood vessels: a new marker for the fetus at
risk. Obstetrics and Gynecology. 1993;81(3):409
411. [PubMed]
[5] Rana J, Ebert GA, Kappy KA. Adverse perinatal
outcome in patients with an abnormal umbilical coiling
index. Obstetrics and Gynecology. 1995;85(4):573
577. [PubMed]
[6] Ezimokhai M, Rizk DEE, Thomas L. Abnormal
vascular coiling of the umbilical cord in gestational
diabetes mellitus. Archives of Physiology and
Biochemistry. 2001;109(3):209214. [PubMed]
[7] Ercal T, Laun S, Altunyurt S, Saygili U, Cinar O,
Mumcu A. Umbilical coiling index: is it a marker for
fetus at risk? The British Journal of Clinical
Practice. 1996;50(5):254256. [PubMed]
[8] De Laat MWM, Franx A, Bots ML, Visser GHA,
Nikkels PGJ. Umbilical coiling index in normal and
complicated pregnancies. Obstetrics and
Gynecology. 2006;107(5):10491055. [PubMed]
[9] Ezimokhai M, Rizk DEE, Thomas L. Maternal risk
factors for abnormal vascular coiling of the umbilical
cord. American Journal of
Perinatology. 2000;17(8):441446. [PubMed]
[10] Gupta S, Faridi MMA, Krishnan J. Umbilical coiling
index. The Journal of Obstetrics &Ganecology of
India. 2006;56(4):315319.
[11] Machin GA, Ackermann J, Gilbert-Barness E.
Abnormal umbilical cord coiling is associated with
adverse perinatal outcomes. Pediatric and
Developmental Pathology. 2000;3(5):462
471. [PubMed]
[12] de Laat MW, van Alderen ED, Franx A, Visser GH,
Bots ML, Nikkels PG. The umbilical coiling index in
complicated pregnancy. European Journal of Obstetrics
&Gynecology and Reproductive
Biology. 2006;70(12):93100.
[13] Kashanian M, Akbarian A, Kouhpayehzadeh J. The
umbilical coiling index and adverse perinatal
Volume 6 Issue 5, May 2017
www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
Paper ID: ART20173609 1584